Generalised Anxiety and Panic Disorder: A NICE CG113 Staff Guide

Anxiety is a normal human response, but when worry becomes constant and hard to control, or panic attacks strike without warning, it can take over a person's life. Generalised anxiety disorder (GAD) and panic disorder are among the most common mental health conditions staff will meet in care, community and primary care settings. NICE guideline CG113 covers how to manage both in adults aged 18 and over, with the aim of complete symptom remission and better day-to-day functioning. This guide explains the guideline in plain language and highlights what staff can do. It is general information, not clinical advice.

Recognising generalised anxiety and panic disorder

GAD involves long-lasting, excessive worry about many everyday matters, along with symptoms such as restlessness, tiredness, difficulty concentrating, irritability, muscle tension and poor sleep. Panic disorder involves recurrent, unexpected panic attacks: sudden surges of fear with symptoms such as a racing heart, chest tightness, breathlessness, sweating, trembling and a feeling of losing control. Many people with panic start to avoid places or situations where an attack might happen, which can lead to agoraphobia. Because panic symptoms resemble heart or breathing problems, staff should never assume that chest pain or breathlessness is simply anxiety. If in doubt, follow your escalation procedure and seek a clinical assessment.

How stepped care works for GAD

NICE sets out a stepped-care model for GAD. Step one is identification, assessment, education and active monitoring. Step two is for people who have not improved: low-intensity interventions such as non-facilitated self-help, guided self-help or psychoeducational groups. Step three is a high-intensity psychological intervention or medicine for those with marked impairment or an inadequate response to step two. Step four is for complex or treatment-resistant cases with severe impairment or significant comorbidity. NICE gives typical lengths: guided self-help of five to seven weekly or fortnightly sessions of 20 to 30 minutes, psychoeducational groups of six weekly sessions of two hours, and CBT or applied relaxation of 12 to 15 weekly sessions of an hour.

Treatment for panic disorder

For panic disorder, NICE recommends recognition and low-intensity support first, followed by CBT or an antidepressant at step three. The quick reference describes CBT of about 7 to 14 hours in total, delivered in weekly sessions of one to two hours over a maximum of four months. When an antidepressant is used for panic, NICE advises review at 2 weeks and then at 4, 6 and 12 weeks, with effectiveness judged by 12 weeks. Whichever treatment is chosen, staff can help by supporting attendance, helping with between-session practice and noticing whether the person is getting better.

Medicines: what is advised and what to avoid

For GAD, NICE recommends sertraline as the first medicine to try, then another SSRI or an SNRI if it does not work. Pregabalin is an option for people who cannot take SSRIs or SNRIs, but it is a controlled drug and requires assessment of any history of misuse. For people prescribed antidepressants, NICE advises review every 2 to 4 weeks for the first 3 months and then every 3 months, and says that someone who responds should continue for at least a year. NICE also says not to offer benzodiazepines except as a short-term measure in a crisis, and not to offer antipsychotics for GAD in primary care. For panic disorder it states that benzodiazepines are associated with a worse long-term outcome and should not be prescribed. Stopping any antidepressant should be gradual, to reduce withdrawal symptoms.

People under 30 who start an SSRI or SNRI need extra monitoring: NICE advises weekly checks for suicidal thinking during the first month. Staff who work closely with people starting a new medicine are well placed to notice agitation, a worsening mood or hopeless comments and pass them on quickly. See our guide to suicide and self-harm awareness training.

Practical ways staff can help

• Stay calm during a panic attack. Speak slowly, stay with the person, and encourage slow breathing. Do not tell them to calm down.
• Do not reinforce avoidance. Encourage small steps towards the situations the person fears, in line with their therapy.
• Keep a simple diary. Notes on triggers, symptoms and how long attacks last help clinicians decide on treatment.
• Look at the whole person. Caffeine, alcohol, poor sleep and loneliness can all make anxiety worse.
• Watch for work-related stress. Employers can find practical tools in the HSE management standards for work-related stress.

When to escalate

Seek urgent help if the person talks about harming themselves, if symptoms suggest a physical emergency, if they are unable to eat, drink or take medicines because of anxiety, or if their condition is clearly getting worse despite treatment. Early recognition is part of good mental health practice, and our mental health first aid training guide sets out how staff can build confidence.

Frequently asked questions

Is anxiety the same as GAD?

No. Anxiety is a normal feeling; GAD is a diagnosable condition in which worry is excessive, persistent and disabling. Only a clinician can make the diagnosis.

Why are benzodiazepines discouraged?

NICE advises limiting them to short-term crisis use because of dependence, sedation and worse long-term outcomes, particularly in panic disorder.

Where can staff find training?

Browse the Learnsignal CPD hub for healthcare compliance and mental health training.

Source: NICE guideline CG113, Generalised anxiety disorder and panic disorder in adults: management; NICE records it as last reviewed in March 2020 with later updates. Check the current version. This article is general information, not clinical advice.